Review of "Living Outside Mental Illness"

By Larry Davidson
New York University Press, 2003
Review by Tony O'Brien, RN, M. Phil. on Jun 20th 2005
Living Outside Mental Illness

Larry Davidson has conducted numerous qualitative studies into aspects of schizophrenia, focusing on the experiences of those diagnosed with this disorder and attempting to make sense of themselves and the world around them. Schizophrenia continues to occupy a problematic position within psychiatric nosology. It is held to be both the most crippling of mental disorders and, for a variety of reasons, something of a psychiatric shibboleth. Mary Boyle, for example, characterizes schizophrenia as a 'scientific delusion'. Antipsychiatrists such as Szasz declare that the notion of mental illness is more than a delusion; there are sinister overtones to the very idea. It is something of a relief then, that Davidson is interested in those with the diagnosis, rather than the high ground of conceptual or nosological certainty. His apparent acceptance of 'schizophrenia' as concept with at least some validity (even if that only means 'those whose ideas and behavior we don't understand and find disturbing') might leave Davidson open to criticism from some quarters, but the cultivated naivety of the qualitative researcher is more concerned with existing language use than analysis of it. In Chapter Four Davidson reminds us that we don't know what schizophrenia is, a reminder that might be given equally to those who resist the concept as to those who accept it as unproblematic.

The book begins with a long introduction that outlines Husserl's phenomenology. This is a broad overview of the relevance of qualitative research to the study of mental illness, and in particular discusses the positioning of the person with mental illness as an experiencing subject, and therefore a partner in collaborative inquiry rather than an object of detached curiosity. In Chapter Two Davidson traces the redefinition of 'recovery' as a key moment in developing mental health services (and practitioners) that attend to the person, and not to some objectified notion of 'illness'. It is in this discussion that the phenomenology that underpins Davidson's work is useful in directing attention from 'schizophrenia' to the experiencing subject. Recovery in the sense used by Patricia Deegan and others has become a difficult concept to pin down. Literature refers to recovery as 'self-defined' and also as 'always occurring', which appears both solipsistic and irremediably subjective, until one accepts that the purpose of such a broad definition is to remind clinicians to seek an understanding what recovery (and illness) means for individual service users. As Davidson points out, even mainstream psychiatry recognizes the need for narrative understandings, and perhaps the inadequacy of an unmodified medical model. The biologically oriented journal Schizophrenia Bulletin has since its inception included a section for first person accounts. Davidson at times talks about whether recovery is possible, suggesting that he does not fully accept that recovery is self-defined. However having freed the term 'recovery' from a narrow biomedical definition of 'freedom from symptoms', and by introducing a subjective component, Davidson clearly establishes the need for narrative understandings of individuals diagnosed with mental illness. The rest of the book provides a reasonable road map for establishing such understandings, and an illustration based on Davidson's work.

Chapter Three explores the question of how to understand the narrative information elicited from qualitative interviews. Davidson refers to 'transcendental reduction', a formidable term, but one which becomes accessible through the discussion of 'intersubjectivity'; the world of interpersonally negotiated meanings. The linking of Husserl's concept of empathy (the researcher's means of accessing interpersonal meaning) with that of Harry Stack Sullivan provides clinicians with a background in interpersonal psychology a welcome foothold in the world of phenomenology.

Despite pursuing accounts that might help us to develop a general understanding of the experience of schizophrenia, Davidson is not concerned with minimizing the complexity of this heterogeneous group of illnesses. Chapters Four and Five describe two populations of participants, those who are extremely disabled by schizophrenia and those who, through a variety of means, have found a way out of disability and as a result have more optimistic stories to tell. The quote from Freud at the beginning of Chapter Four is an interesting choice. The idea of the 'normal person' watching 'hubbub of illness go past like a disinterested spectator' harks back to an earlier psychiatry; one in which stories rather than symptoms were the central point of interest, and the psychiatrist was more akin to an anthropologist than to a medical doctor. The chapters contain interview excerpts of despair, resignation and hopelessness, as well as those describing participants' active engagement in the recovery process. The sheer variety of accounts of what has been helpful is a signal to clinicians to remain alert not only to response to planned interventions, but to the possibility of apparently serendipitous events that can set in motion a process of reclaiming a life. One participant, recounting his involvement with a socialization program, puts it this way:

"It's almost like opening up a little hole in a piece of paper that you kind of poke at and it gets bigger and bigger…I said to myself "why don't you just try and at least do something..." So I went and did something....I actually did something different and I enjoyed it!"

There are other accounts of the sometimes idiosyncratic means that individuals used to cope with their illness. Davidson points to development of a sense of self outside of the identity of 'a person with an illness' as the critical turning point for these participants.

For those whose narratives are of increasing isolation and withdrawal, the contribution of stigma and exclusion looms large, but the apparently negative spiral is not seen as predetermined. The Husserlian notion of identity evolving over time and in active response to interpersonal experiences applies to those diagnosed with schizophrenia not because Davidson and others might prefer to think of them in this way, but because that is the nature of our shared humanity. In the Conclusion Davidson points to lessons that can be learnt from the research, including the damaging effects of stigma and the need on the part of clinicians for an attitude of hope. Both the philosophical commitments of phenomenology and the empirical findings of Davidson's work support this recommendation.

There are many specific aspects of Davidson's book that stood out for me. One research participant described how he established social belonging by engaging in marginal socialization through visits to fast food outlets and other venues that provided an experience of social contact without the complications that might ensue from deeper relationships. From an outside perspective such a pattern of socialization might represent a failure to establish meaningful interpersonal bonds. But in the language of Davidson's participant it was a strategic, adaptive, and meaningful way to gain the amount of social contact judged by the person to be tolerable. Another participant described lack of motivation in terms of his own agency, as a 'goal-directed means of survival'. Yet another used sophisticated metaphorical language to describe her experiences. Jane reported that her food didn't taste the same when she ate alone, and Davidson's subsequent question and discussion pursues the meaning behind this apparently concrete statement to explore the sense of loneliness Jane was referring to. This intent to pursue meaning suggests parallels with, and perhaps the legacy, of Laing.

Living Outside Mental Illness is more than a recapitulation of previously published research. Davidson explains and explores the methodology of Husserlian phenomenology, paying particular attention to the criticism of Husserl's early work which required 'bracketing out' of reality. The chapters on methodology will be valuable for those considering undertaking phenomenological research: if they do not provide a full account of the methods involved, they at least provide a description of one researcher's application of them.

The book will be of value to researchers and clinicians alike. While it contains more practical advice for the former group, clinicians will benefit from the plain language treatment of phenomenology, and from the discussion of examples where the research method of eliciting narrative parallels clinicians' attempts to understand the meanings service users give to their experiences.



2005 Tony O'Brien


 Tony O'Brien, RN, M. Phil., Senior Lecturer, Mental Health Nursing, University of Auckland


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